<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01//EN" "http://www.w3.org/TR/html4/strict.dtd">
<%@page isELIgnored="false" %>
<%@taglib prefix="c" uri="http://java.sun.com/jsp/jstl/core"%>
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
    <title>ACME Labs Demo</title>
    <style type="text/css"><!--
body{font-family:sans-serif; text-align:center;}
div.container{width:600px; text-align:left;}
div.entry {
    clear:both;
}
label {
    width:187px;
    float:left;
    text-align:right;
    padding-top:2px;
    margin-bottom:13px;
    margin-right: 6px;
}
    --></style>
</head>
<body><center>
<div class="container">

    <h2>ACME Labs Test Result Entry Form</h2>

    <form action="/demoacme/demo" method="post">
        <input type="hidden" name="type" value="testresult"/>
        <div class="entry">
            <label>Internal Patient ID</label>
            <input type="text" name="username" value=""/>
        </div>
        <div class="entry">
            <label>Test Ordered by</label>
            <input type="text" name="doctorName" value=""/> from
            <select name="referrer">
                <option value="democommunity" selected="selected">Community Hospital</option>
            </select>
        </div>
        <div class="entry">
            <label>Patient name</label>
            <input type="text" name="name" value=""/>
        </div>
        <div class="entry">
            <label>Patient date of birth</label>
            <input type="text" name="dob" value=""/>
        </div>
        <div class="entry">
            <label>Patient address</label>
            <input type="text" name="address" value=""/>
        </div>
        <div class="entry">
            <label>Patient gender</label>
            <select name="gender">
                <option value="m" selected="selected">Male</option>
                <option value="f">Female</option>
            </select>
        </div>
        <div class="entry">
            <label>Patient ethnicity</label>
            <select name="race">
                <option value="White" selected="selected">White</option>
                <option value="African">African American</option>
                <option value="Hispanic">Hispanic</option>
                <option value="Asian">Asian American</option>
            </select>
        </div>
        <div class="entry">
            <label>Service rendered</label>
            Regular Blood Work
            <input type="hidden" name="serviceName" value="Regular Blood Work"/>
        </div>

        <div class="entry">
            <label>Send Patient?</label>
            <input type="checkbox" name="sendToPatient" value="1"/>
        </div>

        <div class="entry">
            <label>Calcium</label>
            <input type="text" name="testResult1" value=""/>
            mg/dL (Normal 8.4-10.2)
            <input type="hidden" name="testName1" value="Calcium"/>
            <input type="hidden" name="testResultUnit1" value="mg/dL"/>
            <input type="hidden" name="testResultNormalRange1" value="8.4-10.2"/>
        </div>
        <div class="entry">
            <label>Total Protein</label>
            <input type="text" name="testResult2" value=""/>
            g/dL (Normal 6.1-7.9)
            <input type="hidden" name="testName2" value="Total Protein"/>
            <input type="hidden" name="testResultUnit2" value="g/dL"/>
            <input type="hidden" name="testResultNormalRange2" value="6.1-7.9"/>
        </div>
        <div class="entry">
            <label>BUN / GREAT Ratio</label>
            <input type="text" name="testResult3" value=""/>
            ratio (Normal 6.0-20.0)
            <input type="hidden" name="testName3" value="BUN / GREAT Ratio"/>
            <input type="hidden" name="testResultUnit3" value="ratio"/>
            <input type="hidden" name="testResultNormalRange3" value="6.0-20.0"/>
        </div>
        <div class="entry">
            <label>Sodium</label>
            <input type="text" name="testResult4" value=""/>
            mEq/L (Normal 135-145)
            <input type="hidden" name="testName4" value="Sodium"/>
            <input type="hidden" name="testResultUnit4" value="mEq/L"/>
            <input type="hidden" name="testResultNormalRange4" value="135-145"/>
        </div>
        <div class="entry">
            <label>Alanine aminotransferase</label>
            <input type="text" name="testResult5" value=""/>
            IU/L (Normal 19-60)
            <input type="hidden" name="testName5" value="Alanine aminotransferase"/>
            <input type="hidden" name="testResultUnit5" value="IU/L"/>
            <input type="hidden" name="testResultNormalRange5" value="19-60"/>
        </div>
        <div class="entry">
            <label>Potassium</label>
            <input type="text" name="testResult6" value=""/>
            mEq/L (Normal 3.5-5.5)
            <input type="hidden" name="testName6" value="Potassium"/>
            <input type="hidden" name="testResultUnit6" value="mEq/L"/>
            <input type="hidden" name="testResultNormalRange6" value="3.5-5.5"/>
        </div>


        <div class="entry">
            <label>Note</label>
            <textarea name="note" rows="5" cols="45"></textarea>
        </div>
        <div class="entry">
            <label> </label>
            <input type="submit" value="Save"/>
        </div>
    </form>

</div>
</center></body>
</html>
